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Denial of Benefits

If a health insurance company believes it overpaid on previous benefits, can it reduce payments for current, unrelated benefits? The complaint for this class action says it can only if its plan authorizes it. The plan for Blue Cross Blue Shield of Minnesota (BCBSM) does not authorize it, the complaint says, and the reduced benefits paid are a violation of the Employee Retirement Income Security Act (ERISA).

The complaint for this class action notes that certain changes were made to ConAgra Brands Retirement Income Savings Plan in 2015, at the same time as the company laid off around 30% of its workforce. The changes disadvantaged terminated employees, and the complaint claims that ConAgra wanted to save money at their expense. It brings suit under the Employee Retirement Income Security Act (ERISA).

This class action is asking the court to declare parts of Florida law unconstitutional, although the defendant is not the state but a car insurance company. The complaint claims that State Farm Mutual Automobile Insurance Company has been “systematically and routinely denying” all Personal Injury Protection (PIP) claims when the person involved does not receive initial treatment without fourteen days of an accident. According to the complaint, State Farm’s denials are based on “the 2012 PIP amendments” to Florida law.

The complaint for this class action claims that United HealthCare Insurance Co. (UHIC) and United Behavioral Health (UBH) impose reimbursement penalties on claims for coverage for psychotherapy services, which the complaint says is a violation of the Employee Retirement Income Security Act (ERISA) parity provisions and the Affordable Care Act (ACA).

Two minors were denied coverage under their fathers’ Aetna health benefit plans for mental health and substance use programs, the complaint for this class action says, because of the plans had improper exclusions for licensed wilderness therapy programs and licensed residential treatment centers. Both plans are covered under the Employee Retirement Income and Security Act (ERISA) and the complaint says that the denial violates the Mental Health Parity Act, among other things.

How would you feel if you developed an often-fatal liver disease? Now imagine that a cure became available—but your insurer refused to pay for it until the damage to your liver was irreparable? That’s the case with new hepatitis C drugs and Centene Corporation, says the complaint for this class action. The company’s health insurance subsidiaries maintains fibrosis restrictions that the complaint says make no sense in medical terms.

Plaintiff Ronnie Stevenson works for Knight Transportation, Inc. as a truck driver. Knight insists he’s not an “employee” but an “independent contractor,” yet the complaint for this class action alleges that the only difference between Knight’s “employee” truck drivers and its “independent contractor” truck drivers is that the employees receive benefits and the others do not. While there are no hard-and-fast definitions of employees versus independent contractors, the criteria used to judge classification have to do mostly with independence, choice, and control, and the complaint presents evidence that Knight does not allow drivers independence, choice, or control in any significant aspects of their work.

The complaint for this class action claims that insurer USAA hired another company to “review” medical claims submitted to it for Med Pay benefits and that that company used unfair systems to refuse, reduce, or deny claims for benefits for injured people. Some of the bills, the complaint contends, are refused via “coding errors, sham medical necessity reviews, and confidential statistical information, rather than the individual character of health care services required by an insured and their related expenses.” For other ones, the complaint claims that payment amounts are reduced by declaring them “unreasonable” or applying PPO or PPN treatment rates that do not apply to the insureds’ medical providers.

According to the complaint, three-year-old FA has autism spectrum disorder (ASD) and needs Neurodevelopmental Therapy (NDT) and Applied Behavior Analysis (ABA) therapy. Unfortunately, the complaint alleges that the health plan he’s on covers only speech, occupational, and physical therapy for “non-chronic conditions, and acute illnesses and injuries” but does not cover those same services for developmental disabilities. This, the complaint alleges, is a violation of federal ERISA, the Affordable Care Act, and the Mental Health Parity Act, which requires that limitations on services to treat mental health conditions are “no more restrictive” than those applied to medical and surgical benefits.

Defendant Anthem is one of the largest health insurers in the US, and defendant Anthem UM is its claims administrator. The two companies together develop Medical Policies and make decisions on which claims are approved and which are denied. One of their policies is the denial of claims for microprocessor-controlled lower limb prosthesis, the complaint says, on the grounds that they are “investigational and not medically necessary for all indications.” However, the complaint claims that microprocessor prostheses are now standard devices, and that they increase safety and stability, reduce stumbles and falls, decrease discomfort and pain, and aid walking at a variable rate, over varying terrain, or up or down stairs.